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Waste Tire Survey & Inspection Report inspection Report Number <br /> State of California <br /> CalRecycle 11 - 1210259 <br /> CalRecycle R(Rev.y(CalRecycle) Survey <br /> Survey Form - Page 1 <br /> Dept of Resources Recycling and Recovery(CalRecycle) <br /> Part A-Survey BLU_ EOR BLACK INK PEN <br /> Business Profile Inspection Details <br /> TPID- Inspection Type(Fill one) <br /> Site Suffix: ` <br /> 1 �^ CZ � � 3 'l � � ® Routine 0 Re-inspection 0 Referral 0 Observation <br /> Local If Referral,choose referral type(Fill one) <br /> Identifier: ��'���� t '�' 0 CHP 0 CalRecycle 0 Complaint 0 Educational Visit 0 Other <br /> Business or Facility Name (((((( Inspected By Inspector <br /> Physical Address J - ( AiF�,q-vr'L 6,c..l--A <br /> Inspection Date <br /> rx_: -l�n GL4 iSaoS" (7 l <br /> Time In Time Out <br /> Business Rep Title 0 AM / ®AM <br /> 1 O PM l I C O PM <br /> Operational Status Tire Type Business Role Storage Type <br /> Tire Count (Whole/PTE) (Fill one only) (Fill all that apply) (Fill all that apply) (Fill all that apply) <br /> 0 Active 0 Pasgee er 0 Generator 0 / ut <br /> Outdoor <br /> O ®Closed 0 Altered 1IA- <br /> G PS Latitude 0 Hauler 0 Indoor <br /> 0 0 Inactive 0 Truck <br /> Longitude - 0 Planned 0 OTR 0 End-Use 0 Container <br /> Business Type(Fill all that apply) <br /> 0 New Tire Dealer 0 Auto Repair 0 Trucking Fleet 4P Government 0 Retreader 0 Dismantler 0 Tire Derived Fuel <br /> 0 Used Tire Dealer 0 Auto Body 0 Car Dealer 0 Collection 0 Crumb Rubber <br /> 0 Service Station 0 Hauler 0 Agriculture 0 Shredder 0 Other <br /> Part B- Inspection of Waste Tire Dealer, Generator, Hauler and End-Use Facility ENFORCEMENT STATUS <br /> V A HAULING AND MANIFEST REQUIREMENTS <br /> 0 Notice Of Violation 0 Extension <br /> O O <br /> PRC§42951 -Waste Tire Hauler Registration and Transport of Tires <br /> 0 0 PRC§42953-Contracts with Registered Waste Tire Haulers. Compliance Deadline <br /> PRC§42956-Registration/Decal in Vehicle <br /> 0 0 14 CCR§18459-Responsible Entities Complying with Manifesting Requirements Date m <br /> 0 0 14 CCR§18459.1 -Tire Program ID Number from CalRecycle N <br /> 0 0 14 CCR§18459.2.1 -Submittal of Comprehensive Trip Logs within 90 days (Required for NOV or EX1) PL <br /> PL <br /> It <br /> 0 0 14 CCR§18459.3-Retention of Comprehensive Trip Logs for 3 years to <br /> 0 0 14 CCR§18460.2-Manifest System Requirements for Registered Waste Tire Haulers 0 Referred/CalRecycle Enforcement <br /> 0 0 14 CCR§18461 -Manifest System Requirements for Waste Tire End-Use Facilities u, <br /> 0 0 14 CCR§18462-Manifest System Requirements for Tire Dealers or Waste Tire Generators In Compliance-No Violations o <br /> 0 0 Other:§ <br /> z <br /> Comments <br /> -rpa�o t,� 145-4 s 3q s G rxA-,1 4� �!. o 4nv '-�►-�, _t . <br /> -4-- l36 1-7 6 6 . AvA_ <br /> Inspection Form Included: 0 <br /> t 6 -t6Zj <br /> Comments Included: 0 <br /> B ness Rep' ignature Phone Number 9sie4orw4thrialyfe Phone Number <br /> INSTRUCTIONS ON BACK I Correct: Incorrect: X70:V]EEjXj,4 I IMIPIVE11 2 3 62081 <br /> White Copy:CalRecycle Yellow Copy:Operator Pink Copy:LEA <br />